The APACHE II severity of disease classification system has been examined prospectively in 160 patients with acute pancreatitis. Using clinical and simple laboratory data APACHE II was able to provide useful discrimination between uncomplicated, complicated and fatal attacks within a few hours of admission. Peak APACHE II scores (recorded during the first 3 days) had a prognostic accuracy similar to the multiple factor scoring systems, but then incurred a similar delay. Patients could be graded according to their risk of death or of developing a major complication; no deaths occurred in patients with a peak APACHE II score less than 10. APACHE II can be repeated daily, uncomplicated attacks demonstrating falling scores in association with clinical improvement, in contrast to the rising scores associated with clinical deterioration in those dying early. APACHE II appears to reflect any continuing disease activity and may prove a useful means of monitoring the course of the illness and response to therapy.
In a series of patients with acute pancreatitis we have studied complement factors, antiproteases (alpha 2-macroglobulin and alpha 1-antiprotease) and C-reactive protein to determine the value of their sequential measurement in the prediction of outcome relative to clinical assessment and current multiple factor scoring systems. Complement factors were unhelpful in predicting the severity of an attack. alpha 2-Macroglobulin levels were significantly lower in complicated attacks during days 3-8 and alpha 1-antiprotease levels were significantly higher during days 4-8. C-reactive protein concentrations showed the best discrimination between mild and complicated attacks, levels rising higher and persisting for longer in complicated attacks; these differences were highly significant from day 2 (the morning after admission) to day 8. The concentrations providing the best discrimination were found to be greater than or equal to 210 mg/l for the peak C-reactive protein (on the second, third or fourth day) and greater than or equal to 120 mg/l for the C-reactive protein at the end of the first week. Analysis demonstrated both the peak or seventh-day C-reactive protein concentration to be of similar accuracy to either the Ranson or Glasgow multiple factor scoring systems and slightly better for attacks associated with gallstones. The C-reactive protein assay is simple, quick to perform, provides useful clinical information and is more likely to be of value and to be adopted into routine clinical practice than multiple factor scoring systems.
A review of case records and post-mortem reports from Glasgow Royal Infirmary over the past 12 years identified 102 patients with acute superior mesenteric ischaemia, 53 (52 per cent) of whom were first diagnosed at post mortem. Overall mortality was 92 per cent and mortality in the 49 patients diagnosed in life was 84 per cent. Fourteen patients (14 per cent) underwent exploratory laparotomy only with no survivors, 26 (25 per cent) had bowel resection alone with 7 surviving, and 9 (9 per cent) had a revascularization procedure, 5 requiring additional bowel resection, with only one surviving. Survivors were usually younger, had a shorter history and less extensive bowel infarction. Improvements in intensive care and nutritional support with the greater use of revascularization procedures in the past 6 years have barely influenced mortality. Delays in diagnosis and treatment contribute to the poor results. Earlier diagnosis might be aided by measuring serum inorganic phosphate and, coupled with the more widespread use of emergency angiography and revascularization procedures, holds out the best hope for future improvement.
Data on all discharges from hospitals in Scotland have been recorded since 1961 as the Scottish Hospital In-Patient Statistics and examination of these data has permitted analysis of the incidence and mortality trends from acute pancreatitis. The number of discharges recorded has increased 11-fold in males from 69 patients/year in 1961 to 750 patients/year in 1985, and fourfold in females from 112 patients/year to 484 patients/year respectively. This increase has occurred particularly amongst young and middle-aged males (20-59 years) and in elderly females (over 60 years), the most marked increases occurring in the health boards of the 'central belt' area of Scotland. Mortality rate did not show a corresponding change, increasing only two-fold in males from 15 patients/year to 30 patients/year and in females from 29 patients/year to 37 patients/year. As a consequence the case mortality rate has fallen from 17.8 per cent over the period 1961-65 to 5.6 per cent over the period 1981-85. An apparent increase in the incidence of acute pancreatitis may be inferred from these data, much of which is thought to be due to improved accuracy in diagnosis.
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